Feasibility of Using Rideshare Transportation to Reduce Barriers to Participating in a Clinic-based Food Insecurity Intervention.

BACKGROUND: Few clinic-based food insecurity interventions address transportation barriers to utilizing food resources. OBJECTIVES: We assessed the feasibility of using free rideshare-based transportation to reduce barriers to participating in an ongoing clinic-based food insecurity intervention. METHODS: Our multi-methods pilot study used patient surveys (n = 155), focus groups with clinic and program staff (n = 10), and rideshare usage data. RESULTS: Of the 95 (61.2%) survey respondents who reported transportation barriers, only 34 (21.9%) used rideshare. More than 80% of rideshare users rated their experience as good or excellent. Clinic and program staff reported that the service allowed patients a greater sense of control over their time and health and emphasized the need for staffing and program-level infrastructure. CONCLUSIONS: Free rideshare may address transportation barriers for some patients but multiple options for support and adjustments to how we offer transportation solutions are needed to successfully meet the needs of all program participants experiencing transportation barriers.

Measurement of Fruit and Vegetable Intake Incorporating a Diversity, Equity, and Inclusion Lens. Comment on Di Noia, J.; Gellermann, W. Use of the Spectroscopy-Based Veggie Meter® to Objectively Assess Fruit and Vegetable Intake in Low-Income Adults. Nutrients 2021, 13, 2270.

Disparities in fruit and vegetable intake (FVI) and diet-related diseases exist among low-income and racial/ethnic minority populations [...].

Preference for fruits and vegetables is linked to plate waste among preschool children.

BACKGROUND: A large portion of preschool-aged children in the United States (US) do not consume enough fruits and vegetables (FV). It is important for childcare providers to know what food choices children in their care are making at mealtime and how to encourage them to eat more FV. The objective of this pilot study was to examine the relationship between FV preference and plate waste among pre-school aged children in a childcare setting using a rapid assessment tool. METHODS: The rapid assessment tool was first pilot tested with 23 children and revised. A repeated cross-sectional design was carried out for three days during fall 2016 in one childcare center. Over three days, the research team collected 100 FV plate waste observations from 30 children who were surveyed simultaneously about their preference (did not try, tried, liked, loved) towards FV. RESULTS: Food preference for FV by preschool children is significantly (p < 0.05) related to plate waste and age. Children that indicated they loved a fruit or vegetable generated the least plate waste. Children that indicated that they did not try a fruit or vegetable generated the most plate waste. CONCLUSIONS: FV preference and plate waste are significantly and inversely correlated. The rapid assessment tool developed should be validated to be used in implementing strategies that increase child preferences and consumption of FV that support lifelong healthy eating behaviors.

A Photovoice Inquiry Into the Impacts of a Subsidized CSA Program on Participants' Health.

Although consumption of fruits and vegetables is associated with reduced risk of disease, many Americans do not eat the recommended quantity or variety. This is especially true for low-income populations, who may face significant barriers to accessing fresh produce, including cost. Community-supported agriculture (CSA) Partnerships for Health is a subsidized community-supported agriculture program designed to reduce barriers to accessing fresh produce in a low-income population. This Photovoice study gave participants (n = 28) an opportunity to take photos representing how the program affects their lives. The aim was to understand the program's impact from the perspective of CSA members. Participants had 2 to 4 weeks to take photographs, and then selected a few to discuss during a subsequent focus group. Through this discussion, we learned that participants see the program as (a) supporting positive changes to their physical and social health and (b) facilitating learning about new foods, cooking, and agriculture. The study suggests that a reduced-cost CSA membership that incorporates cooking education supports participants' ability to try new foods, build skills, and improve health outcomes.

An ethnographic study exploring factors that minimize lunch waste in Tokyo elementary schools.

OBJECTIVE: To explore factors that minimize lunch waste in Tokyo elementary schools and to consider how such factors can be modified and applied in US schools. DESIGN: Focused ethnographic study using interviews, observation, participant observation and document review. Data were analysed using thematic analysis. SETTING: Tokyo, Japan. PARTICIPANTS: Five school dietitians participated in the study. Data collection methods included in-depth interviews, observation of nutrition education lessons, participant observation of school lunchtime and review of relevant school documents (e.g. lunch menus, food waste records). RESULTS: Five themes emerged from the analysis: (i) reinforcement of social norms to eat without waste; (ii) menu planning to increase exposure to unfamiliar and/or disliked foods; (iii) integration of food and nutrition education into the school curriculum; (iv) teacher lunchtime practices related to portion sizes, distributing leftover food and time management; and (v) engagement of students in reducing school lunch waste. Practical and tangible applications to US schools include measuring and reporting lunch waste to influence social norms, teaching students about the importance of reducing food waste, offering flexible school lunch portion sizes and providing students with meaningful opportunities to contribute to solving the problem of school lunch waste. CONCLUSIONS: Japan offers a model for minimizing school lunch waste through a holistic approach that includes factors that operate at and interact across multiple levels of society. Modifying and applying such an approach in US schools is worth considering given the urgent need to address food waste in order to support healthy diets and sustainable food systems.

CSA Partnerships for Health: outcome evaluation results from a subsidized community-supported agriculture program to connect safety-net clinic patients with farms to improve dietary behaviors, food security, and overall health.

Safety-net clinic patients are at risk for food insecurity, which is associated with poor diet quality and negative health outcomes. Research on the impact of interventions addressing food insecurity in health care settings is limited. The primary aim of this study was to determine the preliminary effectiveness of Community-Supported Agriculture (CSA) Partnerships for Health, a 23 week grant-subsidized CSA program, in improving dietary behaviors, self-efficacy to eat vegetables, food security, and overall health among safety-net clinic patients. This single-group pretest-posttest study used interviewer-administered surveys. Study participants were 48 safety-net clinic patients. Outcomes included fruit and vegetable intake, frequency of dark green and orange vegetable intake, self-efficacy to eat vegetables, eating habits, food security status and ability to afford to eat healthy meals, emotional health, social health, and general health status. Differences in values at postintervention versus preintervention were examined using two-sided paired t-tests, McNemar's tests, and generalized estimating equation models. The difference between postintervention versus preintervention values was statistically significant for a number of outcomes, including vegetable intake (p = .030), orange vegetable intake (p = .004), eating habits (p = .039), food security (p = .039), ability to afford to eat healthy meals (p = .003), and general health status (p = .039). Generalized estimating equation models showed similar associations. CSA Partnerships for Health may have the potential to improve dietary behaviors, reduce food insecurity, and improve overall health among safety-net clinic patients.

Strengthening adolescents' connection to their traditional food system improves diet quality in remote Alaska Native communities: results from the Neqa Elicarvigmun Pilot Study.

In remote Alaska Native communities, traditional foods are inextricably linked to health and food security. Degradation of the traditional food system over the past several decades has resulted in a shift in dietary patterns that have contributed to increased rates of chronic diseases and food insecurity among Alaska Native People. Interventions are needed to address this. Our objectives were to evaluate the preliminary efficacy of a school-based intervention-Neqa Elicarvigmun or the Fish-to-School Program-on diet quality, fish intake, and attitudes and beliefs around traditional foods (specifically fish) using a pre-post comparison group design with data collection occurring at three time points. Study participants were 76 middle and high school students in two remote Alaska Native communities (population <900) in southwestern Alaska. We used a participatory approach to design the school-based, multilevel intervention that included activities in the cafeteria, classroom, and community. Multilevel analyses showed that students in the experimental community showed significant improvements in diet quality compared to the comparison community (Beta = 4.57; p < .05). Fish intake, measured using the stable nitrogen isotope ratio of hair, a validated biomarker, also increased significantly in the experimental community (Beta = 0.16; p < .05). Leveraging the cultural and physical resources of the traditional food system for the Neqa Elicarvigmun program represents a strength-based approach that improves diet quality, increases adolescents' connection to their traditional culture, and by promoting the local food system supports food security. Embedding the program into the local culture may result in faster adoption and greater sustainability of the program.

Feasibility of Using a Community-Supported Agriculture Program to Increase Access to and Intake of Vegetables among Federally Qualified Health Center Patients.

OBJECTIVE: This study explored the feasibility of using a 23-week subsidized community-supported agriculture program to increase access to and intake of vegetables among Federally Qualified Health Center patients. METHODS: Outcomes were measured using pre-post intervention surveys (n = 9). Process data were collected in post-intervention surveys and focus groups (n = 15). RESULTS: Most participants (77%) indicated that the program improved their health and all (100%) reported that they were eating a greater variety of vegetables because of their participation in the program. Three themes emerged from the focus groups: increased access to fresh and/or organic vegetables, improved diet quality, and the importance of social support during the program. CONCLUSIONS AND IMPLICATIONS: Linking subsided community-supported agriculture programs with Federally Qualified Health Centers has the potential to increase access to and intake of vegetables among low-income patients. However, further research is needed with a larger sample size and a more robust study design.

Teaching Undergraduate Students to Visualize and Communicate Public Health Data with Infographics.

The purpose of this study was to explore the degree to which an infographic assignment facilitated student learning around health science issues, as well as the ways in which the assignment was an effective teaching tool. The objectives of the assignment were to (1) understand the purposes of and potential uses for infographics, (2) cultivate creative visual communication skills, and (3) disseminate a complex health topic to diverse audiences. The infographic assignment was developed at Montana State University and piloted at Portland State University. Students were assigned to small groups of three or four to create an infographic focused on a health science issue. The assignment was divided into four steps: brainstorming, developing, designing, and finalizing. Focus groups were conducted to assess how learning occurred throughout the assignment and identify any opportunities for modification of the assignment. This study was conducted with freshman students enrolled at Portland State University, a public university located in downtown Portland, OR, USA. Thirty four students completed the assignment and 31 students participated in one of three focus groups. Four themes emerged from focus groups: (1) Communicating Science-Related Topics to Non-experts, (2) Developing Professional Skills, (3) Understanding Health Issues, and (4) Overall Experience. This article outlines the assignment, discusses focus group results, and presents assignment modifications. It is clear that the infographic assignment facilitated learning about accessing and translating data. This assignment is ideally suited for use with diverse college-age audiences in health education and health promotion fields.

Corrigendum: Teaching Undergraduate Students to Visualize and Communicate Public Health Data with Infographics.

[This corrects the article on p. 315 in vol. 5, PMID: 29226120.].

A Cooking Intervention to Increase Vegetable Consumption by Parents With Children Enrolled in an Early Head Start Home Visiting Program: A Pilot Study in Portland, Oregon, 2013-2014.

INTRODUCTION: Cooking interventions may improve diet quality. Most cooking interventions are delivered in group settings. Home visiting programs may be an appropriate mechanism for delivering such interventions to low-income families with young children. We conducted a pilot study to test the feasibility of using a cooking intervention delivered by home visitors to improve attitudes and behaviors related to vegetable consumption by low-income parents with children enrolled in a home visiting program. METHODS: We invited 121 parents with children enrolled in an Early Head Start Home Visiting program in Portland, Oregon, to participate. During 2013-2014, each month for 8 months, home visitors (n = 14) implemented 1 cooking activity plus 1 complementary activity focused on 12 vegetables. We collected pre- and post-intervention data on participants' cooking confidence and whether they tried and liked the selected vegetables. We also measured fidelity to protocol and home visitors' perception of intervention usability. RESULTS: Of 104 participants, 58 provided pre- and post-intervention data. We observed a significant increase in confidence in baking, roasting or grilling vegetables; cooking 6 of 10 vegetables; and trying 7 of 12 vegetables. Nearly all respondents participated in the monthly cooking activity (96%) and complementary activity (94%). Twelve of 14 home visitors reported that the intervention was acceptable, feasible, and easy to understand, and needed systems supports to implement. CONCLUSION: Cooking interventions may be a feasible approach to improving attitudes and behaviors related to vegetable consumption by low-income families with young children. Additional research is needed to assess the impact of such interventions on vegetable consumption.

Food-related practices and beliefs of rural US elementary and middle school teachers.

INTRODUCTION: Childhood obesity disproportionately affects rural populations; therefore, promoting healthy eating among rural children is essential. Teachers are important role models for children and can influence children's eating behaviors through their own behaviors and beliefs about food. This study examined the food-related practices and beliefs of rural elementary and middle school teachers. METHODS: Data were used from the SNACZ study, a school- and community-based trial conducted in rural Oregon. Kindergarten through eighth-grade teachers (n=87), teaching students usually aged 5-14 years, from eight rural school districts completed a baseline survey in November 2012 concerning their classroom food practices, eating behaviors at school, beliefs about the school food environment, and nutrition knowledge. Frequencies of responses to each item were calculated. RESULTS: Nearly all teachers (97.6%) agreed that a healthy school food environment is important, but fewer agreed that teachers' behaviors and the foods available at school influence students' eating behaviors (71.0% and 67.0%, respectively). Nearly 86% of teachers used candy as a reward for students, while 78.2% consumed unhealthy snacks and 42.5% consumed sweetened beverages in the classroom. CONCLUSIONS: The results suggest that most rural teachers recognize that having a healthy school food environment is important, but are less aware of factors within the school that influence students' eating behaviors - including their own eating behaviors and classroom food practices - and, perhaps for this reason, many rural teachers engage in classroom practices and behaviors that do not promote healthy eating. Teacher training and expanded school policies that focus on teacher behavior may be needed to ensure a healthier rural school food environment.

Formative Evaluation to Increase Availability of Healthy Snacks and Beverages in Stores Near Schools in Two Rural Oregon Counties, 2013.

INTRODUCTION: Children living in rural areas are at greater risk for obesity than their urban counterparts. Differences in healthy food access may contribute to this disparity. Most healthy food access initiatives target stores in urban areas. We conducted a formative evaluation to increase availability of healthy snacks and beverages in food stores near schools in rural Oregon. METHODS: We assessed availability of healthy snacks and beverages in food stores (n = 15) using the SNACZ (Students Now Advocating to Create Healthy Snacking Zones) checklist and conducted in-depth interviews with food store owners (n = 6). Frequency distributions were computed for SNACZ checklist items, and interview data were analyzed by using applied thematic analysis. RESULTS: Overall, availability of healthy snacks and beverages in study communities was low. Four interrelated themes regarding store owner perspectives on stocking healthy snacks and beverages emerged from the interviews: customer demand, space constraints, vendor influence, and perishability. CONCLUSION: In addition to working with food store owners, efforts to increase availability of healthy snacks and beverages in rural areas should engage young people, food buyers (eg, schools), and vendors as stakeholders for identifying strategies to increase demand for and availability of these items. Further research will be needed to determine which strategies or combinations of strategies are feasible to implement in the study communities.

Harvest for Healthy Kids Pilot Study: Associations between Exposure to a Farm-to-Preschool Intervention and Willingness to Try and Liking of Target Fruits and Vegetables among Low-Income Children in Head Start.

BACKGROUND: Most US children do not meet recommendations for daily fruit and vegetable intake. OBJECTIVE: Our aim was to evaluate the hypothesis that at post-intervention, children exposed to the Harvest for Healthy Kids pilot study will have greater willingness to try and liking of target foods vs children in the comparison group, controlling for baseline differences. DESIGN: We conducted a quasi-experimental pilot study with comparison, low-intervention, and high-intervention groups. Pre- and post-intervention survey data were collected. PARTICIPANTS/SETTING: The intervention period was October 2012 to May 2013. The analysis sample was 226 children within the higher-level unit sample of five participating Head Start centers (Portland, OR); 231 children dropped out of or enrolled in Head Start mid-year, were absent during or refused to participate in the assessments, or were missing covariates. INTERVENTION: The comparison group received no intervention components; the low-intervention group received foodservice modifications; the high-intervention group received foodservice modifications and nutrition education. MAIN OUTCOME MEASURES: Willingness to try and liking of target foods were tested and analyzed as binary variables. STATISTICAL ANALYSES PERFORMED: McNemar's tests were used to assess differences between pre- and post-intervention scores by intervention group. Fixed slope, random intercept multilevel logistic models were used to assess associations between intervention group and post-intervention scores controlling for covariates, adjusting for baseline values, and accounting for center level clustering. RESULTS: The difference between pre- and post-intervention willingness to try and liking of target foods was statistically significant for a variety of foods; for example, 44.2% of children liked rutabaga pre-intervention compared with 78.1% post-intervention (P=0.004). Multilevel modeling indicated similar associations. CONCLUSIONS: The Harvest for Healthy Kids pilot study suggests a positive association between the intervention and willingness to try and liking for target foods among study participants. Additional research is needed to assess the impact of the program on fruit and vegetable intake.

Leader Behaviors, Group Cohesion, and Participation in a Walking Group Program.

INTRODUCTION: Less than half of all U.S. adults meet the 2008 Physical Activity Guidelines. Leader behaviors and group cohesion have been associated with increased participation or adherence in sports team and exercise class settings. Physical activity interventions in community settings that encompass these factors may enhance intervention adherence. The purpose of this study is to examine the impact of Community Health Promoter leader behaviors and group cohesion on participation in a walking group intervention among racially/ethnically diverse adults in low to moderate-income communities in Detroit, Michigan. DESIGN: Data for the current study were drawn from the Walk Your Heart to Health (WYHH) data set. WYHH was a multisite cluster RCT with a lagged intervention and outcome measurements at baseline and 4, 8, and 32 weeks. Pooled survey data from both intervention arms were used for the current study. Data were analyzed between August 2013 and October 2014. SETTING/PARTICIPANTS: A total of 603 non-Hispanic black, non-Hispanic white, and Hispanic adults across five cohorts that began the 32-week WYHH intervention between March 2009 and October 2011. INTERVENTION: The intervention was a 32-week walking group program hosted by community- and faith-based organizations and facilitated by Community Health Promoters. Walking groups met three times per week for 90 minutes per session. To promote participation in or adherence to WYHH, Community Health Promoters used evidence-based strategies to facilitate group cohesion. Group members assumed increasing leadership responsibility for facilitating sessions over time. MAIN OUTCOME MEASURES: Participation in WYHH as measured by consistency of attendance. RESULTS: Community Health Promoter leader behaviors were positively associated with participation in WYHH. Social but not task cohesion was significantly associated with consistent participation. Social cohesion may mediate the relationship between leader behaviors and walking group participation. CONCLUSIONS: Providing leaders with training to build socially cohesive groups may help motivate individuals to continue participation in community-based physical activity programs.

Effects of particulate matter and antioxidant dietary intake on blood pressure.

OBJECTIVES: We assessed 2 pathways through which dietary antioxidants may counter adverse effects of exposure to particulate matter less than 2.5 micrometers in diameter (PM2.5) on blood pressure (BP): main (compensatory) and modifying (protective) models. METHODS: We used 2002 to 2003 data from the Detroit Healthy Environments Partnership community survey conducted with a multiethnic sample of adults (n = 347) in low- to moderate-income, predominantly Hispanic and non-Hispanic Black neighborhoods in Detroit, Michigan. We used generalized estimating equations to test the effects of ambient exposure to PM2.5 and dietary antioxidant intake on BP, with adjustment for multiple confounders. RESULTS: Dietary antioxidant intake was inversely associated with systolic BP (b = -0.5; P < .05) and pulse pressure (b = -0.6; P < .05) in neighborhoods closest to major sources of air pollutants. Adverse effects of PM2.5 remained significant after accounting for antioxidant intakes. Exploratory analyses suggested potential modifying effects of antioxidant intake on associations between ambient PM2.5 exposure and BP. CONCLUSIONS: Interventions to improve access to antioxidant-rich foods in polluted urban areas may be protective of cardiovascular health. However, efforts to reduce PM2.5 exposure remain critical for cardiovascular health promotion.

Availability of healthy snack foods and beverages in stores near high-income urban, low-income urban, and rural elementary and middle schools in Oregon.

BACKGROUND: Food stores near schools are an important source of snacks for children. However, few studies have assessed availability of healthy snacks in these settings. The aim of this study was to assess availability of healthy snack foods and beverages in stores near schools and examine how availability of healthy items varied by poverty level of the school and rural-urban location. METHODS: Food stores were selected based on their proximity to elementary/middle schools in three categories: high-income urban, low-income urban, and rural. Audits were conducted within the stores to assess the presence or absence of 48 items in single-serving sizes, including healthy beverages, healthy snacks, fresh fruits, and fresh vegetables. RESULTS: Overall, availability of healthy snack foods and beverages was low in all stores. However, there was significant cross-site variability in availability of several snack and fruit items, with stores near high-income urban schools having higher availability, compared to stores near low-income urban and/or rural schools. Stores near rural schools generally had the lowest availability, although several fruits were found more often in rural stores than in urban stores. There were no significant differences in availability of healthy beverages and fresh vegetables across sites. CONCLUSIONS: Availability of healthy snack foods and beverages was limited in stores near schools, but these limitations were more severe in stores proximal to rural and low-income schools. Given that children frequent these stores to purchase snacks, efforts to increase the availability of healthy products, especially in stores near rural and low-income schools, should be a priority.

Inter-rater reliability of a food store checklist to assess availability of healthier alternatives to the energy-dense snacks and beverages commonly consumed by children.

BACKGROUND: Food stores have gained attention as potential intervention targets for improving children's eating habits. There is a need for valid and reliable instruments to evaluate changes in food store snack and beverage availability secondary to intervention. The aim of this study was to develop a valid, reliable, and resource-efficient instrument to evaluate the healthfulness of food store environments faced by children. METHODS: The SNACZ food store checklist was developed to assess availability of healthier alternatives to the energy-dense snacks and beverages commonly consumed by children. After pretesting, two trained observers independently assessed the availability of 48 snack and beverage items in 50 food stores located near elementary and middle schools in Portland, Oregon, over a 2-week period in summer 2012. Inter-rater reliability was calculated using the kappa statistic. RESULTS: Overall, the instrument had mostly high inter-rater reliability. Seventy-three percent of items assessed had almost perfect or substantial reliability. Two items had moderate reliability (0.41-0.60), and no items had a reliability score less than 0.41. Eleven items occurred too infrequently to generate a kappa score. CONCLUSION: The SNACZ food store checklist is a first-step toward developing a valid and reliable tool to evaluate the healthfulness of food store environments faced by children. The tool can be used to compare availability of healthier snack and beverage alternatives across communities and measure change secondary to intervention. As a wider variety of healthier snack and beverage alternatives become available in food stores, the checklist should be updated.